From systems to evidence: a study in applying complexity theory to a health promotion programme

Introduction
This paper focuses on the application of complexity theory to a WHO/Europe-backed health promotion programme, the National Healthy School Standard (NHSS) in England. Having developed a version of complexity theory suited to general use, I have applied this in developing systems and evidence products and services for the NHSS team(1). Faced with complex, confusing and conflicting issues on a daily basis (2) I have sought to apply complexity to support the aims of the programme:

Developing the team from ‘silo-working’ to greater co-ordination within a public health organisation

Leading the design of IT systems to capture and deliver evidence from schools

The larger task of providing evidence of impact out in the real world in the next phase of the programme remains (3). Here the input of complexity is more explicit in terms ranging from the contribution of a complexity consultant on the subject of what constitutes evidence, through to designing IT systems to capture and deliver evidence. Functionally speaking this database links the organisation and operation of the team around complexity lines, with the organisation and operation of evidence, linking ‘implicit’ complexity with ‘explicit’ complexity (4).

Developing the team from ‘silo-working’ to greater co-ordination

1. Proving the impact of complexity on team systems – where complexity theory can bridge the gap
The advantage of a traditional scientific approach is that you can prove impact, in that by the logic of the process both inputs, and outputs are readily measurable. My question is but does that work in the complex interactive environment our team works in where ambitious targets including reducing health inequality, increasing social inclusion and improving school attainment are headline goals? So while the disadvantage of my approach is that all I have to go on in terms of outputs is qualitative, anecdotal evidence of success, the hypothetical advantage is that I can lock more closely with the root of the problem, because essentially the root is complex. Complex problem requires complex-base solutions. The mechanism to deliver on elements of that solution may be simple and linear, but that is within the context of this wider understanding of problem/solution. The relationship is therefore different, linear is a sub-set of non-linear, if you like: “With regard to evidence, the complexity of multi-disciplinary, compound interventions make simple, universal, rules of evidence, untenable. Existing rules of evidence are often based on interventions that have relatively simple, demonstrable chains of causation where single factors are manipulated to produce single easily measured outcomes. Many community-based health interventions include a complex mixture of many disciplines, many variables of varying degrees of measurement difficulty, and dynamic changing settings. In short, understanding multi-variate fields of action that may require a mixture of complex methodologies and considerable time to unravel any casual relationships. New analyses may reveal some critical outcomes years following an intervention. Thus, there is a need to recognize the complexity issue as it pertains to community interventions and suggest areas needing development to better understand analytical challenges. There is a need to develop and support more appropriate analytical methods and evaluation designs.” (5)

2. The appliance of science
Definitions of complexity theory gets murkier the further it gets from maths and the closer it gets to people going about their day to day work, but conversely that is also where it can leverage some of its greatest value. Not surprisingly therefore attempts to make its application to health policy and practice is nothing new. For example here are seven points on complexity cited in a briefing produced by the NHS Confederation (6):

The scientific study of complex systems is challenging notions about control, change, progress, predictability, and static order

In complex systems the elements of the system can change themselves

Very complex outcomes can emerge from a few simple rules

Complex adaptive systems are non-linear

Complex systems thrive in tension and paradox

Leaders in complex systems manage generative relationships

Leaders in complex systems need to learn to think and work in different ways from yesterday’s norm.

Faced with the fuzzy task of improving team systems I sought to use these kind of complexity principles and translate them into action in a way superficially not dissimilar to a standard OD consultant using complexity does. Obviously, a crucial difference was that I was there as a member of staff, and a relatively junior one. This gave me the opportunity to utilise my intellectual property and implement systems on very much a micro (almost invisible), level where selling the benefits of each suggestion was key to their success (7). Of course, when dealing with the fine details of team integration my relatively lowly position was a positive godsend. For in theoretical terms not only as complexity theory would suggest, knowing these micro elements allowed me to help the team understand the relationship between the parts of the programme when re-orientated around evidence as the ‘systems key’. But also in this lowly position, without the benefit of the conventional power relationship not only was I forced to sell the benefits, the exchange of intellectual property was conducted within the realm of minutiae which is on an interactive/relationship basis (8), making it more powerfully effective in winning hearts and minds in terms of real change.

3. Context analysis
How has the application of complexity theory helped the team? First, I should make it clear that I am considering this in both academic terms, but also as a member of the team – a fundamentally different position from which to understand and apply complexity – and one which delivers the innovative core of this paper. Secondly, that the context can be dated back to February 2002 with the need to move the team into a different phase presented to the team by the line manager, responsible for managing the NHSS, Young People’s Health Network, and Wired for Health website series under the collective banner of the Schools and Young People’s Health Team (SYPHT). Thirdly, in simple baseline terms based on my observations from the previous 15 months, a few of the key interlocking problems included:

Individual project teams activity lead rather than task lead

Poor shared understanding of the work of different projects across the team, and specifically the aims and objectives of the core NHSS programme

Ignorance across the HDA host organisation of the work of the team.

Formally speaking the change to remove silo working and integration didn’t require an injection of complexity theory, it happened anyhow with the introduction of a flat management structure. (9) Where I thought it could play a role was in delivering the finer details of that change – and here we go back to the innovative core of my work. Fortunately my line manager agreed that work at the details level was of benefit, and I was provided with a generous team systems budget, and left to work out how exactly I could support the integration. (10)

Capturing evidence & connecting the team: the design and build of a dual-function database

1. The birth of the database
So how to translate complexity, whether explicit or implicit, into some tangible benefits for the team? Guided by my line manager’s need to prove evidence of impact to the primary funder, the Department of Health, a pilot database was constructed in 2002 (11). Evaluation revealed that the case studies captured in this pilot were too descriptive – basically they needed to be ‘SMART-er’. An expert consultant was recruited to research and design a case study framework which would meet these needs. Now underway is the process of building the architecture to deliver that case study framework, and in addition provide an up-to-date source of contacts for the team. While it’s an output about to happen (11a), I want to travel back in time to look for signs of complexity adding value to the process.

For example, the diagram below was just one tool I used in an attempt to show the dynamic of inputs and outputs with evidence at the centre (XX):

Conclusion to it all – looking to the future
How & why the application of complexity theory has contributed to the aim from April 2003 to be for all schools with 20% or more free school meals – FSM – (approximately 7000 nationally) to achieve ‘level three NHSS status’ by 2006, while at the same time retaining the universality of the programme.

(And to consider if there is any added value by linking the internal and external functions of the database under one roof beyond mere technical logic?)

References

(1) I had first developed my version of complexity with papers on self-empowerment, & new technology, before seeking to applying this understanding to help meet the needs of the programme team My 1999 paper on non-linear empowerment. My 2000 paper in Birmingham on complexity and technology. I began work at the Health Development Agency in September 2000, and since March 2002 I have been responsbile for developing
team ‘systems’ and evidence.

(2) “Typically, health promotion initiatives are complex in that they embrace a multi-dimensional appraoch, mixing the five Ottawa strategies..(building healthy public policy; creating supportive environments; strengthening community action; developing personal skills; reorienting health services)..and tending to adopt multi-level action – at national, regional, local and school level, (Springett, 1999). The NHSS typifies this complexity through the promotion of a ‘whole school approach’ and in operating at a national,
regional, local and school level.” From ‘Evaluating the National Healthy School Standard: a study of different stakeholders’ perseholder perspectives’, MSocSci dissertation, 2001, C.L. Jones.

(3) The aim from April 2003 to be for all schools with 20% or more free school meals – FSM – (approximately 7000 nationally) to achieve ‘level three NHSS status’ by 2006, while at the same time retaining the universality of the programme.

(4) My two direct project managers on the Wired for Health team were removed as I was promoted on to the same level, along with other newly promoted team members. A little later two new staff were brought in to handle the growing administrative needs of the team, followed a few months later by a third.

(5) Leading Edge 1, NHS Confederation, Oct 2001.

(6) “Management theory has gradually accepted that “hidden” assets (knowledge of employees, but also customer and supplier relations, brand loyalty, market position and knowledge) increasingly play a major role for the survival of more companies. “(Intellectual capital) is becoming corporate America’s most valuable asset and can be its sharpest competitive weapon. The challenge is to “find what you have – and use it” wrote Thomas Steward in Fortune almost five years ago (ref). “These ‘assets’ are hidden because they do not show up on the balance sheet of companies. At the same time, as business journals and magazines demonstrate almost daily, many senior executives realise
that successful companies will be those who do the best job of capturing, nurturing and leveraging what employees know.”
‘Measuring your Company’s Intellectual Performance’, J & G Roos,Long Range Planning, Special Issue on Intellectual Capital Vol. 30, No. 3, 1997, pp. 413-426.

Certainly something seems to be working as the quality of the NHSS systems were recently positively appraised in two separate focus groups undertaken by external OD consultants Empower on behalf of the host organisation, the Health Development Agency (HDA).

(8) Evaluation in health promotion : principles and perspectives edited by Irving Rootman … [et al.]; Chapter 4, ‘What Counts as Evidence? Issues and Debates on Evidence Relevant to the Evaluation of Community Health Promotion Programs,’ David McQueen and Laurie M. Anderson. Available as a downloadable PDF from the WHO Europe website www.who.dk

(9) The National Healthy School Standard (NHSS) is housed within the Health Development Agency (HDA). The HDA is a special health authority established to identify the evidence of what works to improve people’s health and reduce health inequalities. It works alongside professionals to get evidence into practice, advising and supporting policy makers and practitioners. The HDA started on 3 April 2000. It has a staff of approximately 120 and an annual budget of £10 million. [Note that the HDA was merged with NICE in 2005].

(10) This experience suggests several hypotheses about the factors related to the explicit use of complexity models and concepts with organizational clients. The hypotheses are taken from ‘Dilemmas of being Explicit about Complexity Models’, Edwin E. Olson, paper presented at the 12th Annual Conference Society for Chaos Theory in Psychology& Life Sciences, PSU.

(11) Pilot database created in collaboration with the University of London Computer Centre.

(11a) The Schools and Young People’s Health Team Dual Function Database is due to have completed its construction by RIMA Design by 4 April 2003.

(=) A copy taken from a sketched diagram first created in May 2002.
(XX) Medical Research Council definition quoted by Stephanie Taylor in a presentation on ‘Understanding and Evaluating Complex Interventions in Healthcare – Will Synthesis of Different Types of Research Evidence Hold the Answers?’, 2003.